Sunday, February 28, 2016

Psychiatry With And Without A Conscious State

One of the great attractions of psychiatry for me - is the skill set that you have to develop to understand a person's real problems. By real problems - I mean the problem or problems that brought them in to see you in the first place. I am not talking about the problem listed on a referral sheet, or spoken in a telephone call, or even described to you by another physician or family member. Advocacy groups and some psychiatrists tend to be self congratulatory on the amount of information about psychiatric disorders that is out there. There is an excessive amount of confidence in lists of symptoms being the same thing as a diagnosis. Any psychiatrist will tell you that the number of people who walk into the office and proclaim they have depression, bipolar disorder, or attention deficit-hyperactivity disorder is at an all time high. They typically come to that conclusion by some combination of listening to TV ads or friends and family members. In some cases they are directed to Internet sites where they can take a brief quiz to determine the diagnosis. In almost all cases they are wrong. Interviewing people to come up with both diagnoses and diagnostic formulations - is a considerable skill set that cannot be replicated by handing that person a symptom checklist or interviewing them like a talking checklist.

The problem in cases of self-diagnosis is that most people have a limited awareness of what diagnosable mental illness is. They get their ideas from a static checklist or advice from a person who has not seen hundreds of people with the condition. That process is often a checklist by proxy as in "I read this checklist in a magazine and you seem to have the symptoms. You must have bipolar disorder." In many ways that is like reading a manual about how to repair a complicated problem with your car. Some untrained people may be able to pull that off, but thevast majority will fail. The failure will occur at the level of pattern matching with the severe problems as well as the appropriate assessment of biases along the way. That is not to say that experts are free of bias, but they are less susceptible to the common biases that occur along the way largely due to an accumulation of patterns that they have encountered over the course of their careers.

To develop the best possible understanding of psychiatric diagnosis and how it works might require consideration of some overlapping models of the conscious state in humans. Consciousness is a complicated process concept, but it basically refers to the collection of mental processes that result in a stable personality and behavior over time. An example of elements of consciousness is included in the representation below. It contains descriptions that are found in the writings of David Chalmers and other authors on consciousness. Chalmers breaks consciousness down into the easy problems or readily observable properties of consciousness and the hard problem. The hard problem involves figuring out how the neurobiological substrate can generate conscious states and how those states are all unique. There are a lot of theories about how that might happen, but none of them have been proven.

The psychiatric assessment is trying to determine the parameters listed in the box at the right. Some of the properties of consciousness are listed in the box at the left. There is not a clear correlation between these elements, but what needs to be elicited in the interview will be determined to a large extent by the conscious state of the individual. As an example, if I am interested in asking about sleep, I routinely take a sleep history that goes back to childhood. I ask about insomnia, nightmares, night terrors, sleepwalking, and all of those states over the decades that gets me to the current age of my patient. As an adult I ask about whether or not they have had polysomnography, whether they snore or have restless legs at night. I ask them about the medical and non-medical treatment they have received for insomnia and if there were any complications. I have to observe whether or not the person can reasonably respond to those questions or not and a lot of that depends on their conscious state.

In order to make a psychiatric diagnosis of a basic mood disorder, the primary criteria is that there has been a phasic mood disturbance for a certain duration. In the case of depression the primary DSM-5 criteria is: "Depressed mood most of the day, nearly every day, as indicated by subjective report or observation made by others" or "Markedly diminished interest or pleasure in all, or almost all activities, most of the day, nearly every day." That basic distinction taxes the conscious state of many people who are already diagnosed with mania or depression. Wait a minute - "most of the day, nearly every day" - don't I have good days and bad days." The number of people who make that observation when they are asked the specific question is significant. When I hear that response, I remember the pre-DSM Feighner criteria for intermittent depression. In those days it was acceptable to have good days and bad days. Today in a complicated process occurring in the person's conscious state they need to decide if this phasic mood disturbance really applies or if there are other reasons for endorsing a positive response. If they are handed a standard checklist for depression like the PHQ-9, the conscious thought process is much different than a psychiatrist asking them about an all encompassing mood disorder rather than "good days or bad days."

The process might even have to take a step farther back when the patient states: "Wait a minute doc, I am not sure that I know what anxiety or depression really is. Aren't they the same thing? Doesn't one turn into the other? Can you explain it to me?" This is a much different interview than a person coming in and declaring a problem. This person is aware that some kind of problem exists. They may have learned that from feedback from a spouse or an employer. They don't know what to call it. They might be aware of physical distress, but be unable to make the connection to emotional perturbations. Is their concept of a disorder the same as the person who comes in declaring themselves to have the problem. Probably not, but it is apparent to me from interviewing tens of thousands of people over the past thirty years that everyone has a slightly different idea of the problem. It is obvious that it is also a much different situation when the patient is handed a checklist of symptoms of depression and makes what is essentially a series of forced decisions about if they have depression and how severe it is. Consciousness researchers have used the thought experiment about the color red for years. That is, my experience of the color red, is probably different from your experience of the color red. In other words, my conscious state processes the color red in a different and unique way compared with your conscious state. Why would that not be true with regard to the various types of depression and anxiety?

That brings me to another conceptualization that is often used to look at diagnoses like the dementias, schizophrenia, and attention deficit-hyperactivity disorder. The abilities to plan, act, and perform these acts successfully is often referred to as executive function. Although these functions tend to be arbitrary and arrived at by consensus, they have always been important in psychiatric diagnoses. Major mood disorders, schizophrenia, and neurocognitive disorders may all have varying degrees of impairment in executive function. Testing specific functions and trying to correlate them with behavior at the clinical level is frequently disappointing except in cases of significant brain damage. By inspection, it is apparent that there is an overlap between executive functions and consciousness - but not a complete mapping by any means. DSM-5 has a fairly extensive table on six Neurocognitive Domains (pages 593-595) that describes executive function as one of these domains. Executive function is defined as planning, decision-making, working memory, inhibition, mental flexibility, and responding to feedback. Clear examples of what can be observed in each case are given. Neurocognitive disorders are clear problems in consciousness.

The common psychiatric approach to diagnosis and treatment is what I would call a biomedical approach. It was elaborated on by George Engel in his famous paper on the biopsychosocial approach to medicine, but it was practiced extensively before that paper was written. A lot of the social and familial aspects of this interview were undoubtedly influenced more by epidemiology and genetics rather than consciousness factors. It has been known for some time that you make be more likely to have a heritable illness if it runs in your family or it occurs in members of your occupation. But what does a psychiatrist also need to know about how anxiety develops. Can it be transmitted directly from a parent who is a "worry wart" to a child? Does the child recognize it at the time? Do children remember when their father was enraged or their parents were fighting and they were wide awake listening to it all night long? Do people remember what it was like to "walk on eggshells" due to all of this adversity occurring during their childhood? Do all of these incidents affect elements of their conscious state that keep them stuck in what are defined as psychiatric disorders? Without a doubt.

Conscious states are important in both the diagnosis and treatment of psychiatric disorders, but for the purpose of this post I am ending on diagnostic considerations as noted in the first slide of this series. I will briefly comment on the importance of each dimension.

Interview Context: Psychiatrists are called on to provide services in a wide variety of environments. The appropriateness of the environment for both assessment and treatment needs to be assured. It is common for a third party to want to restrict access to the time of psychiatrists by rationing their time with the patient or total time allowed to see each patients. Times vary greatly from system to system. In some cases, a the time allocated for a new evaluation is 30 minutes and in others it can be up to 90 minutes. I have completed complete interviews at both ends of the spectrum, but the limiting factor can never be some preconceived notion by an administrator. The patient's conscious state is the limiting factor. That includes how they respond to the psychiatrist and the introductory process of the interview. It also depends on a quiet confidential environment and whether there are any observers in the room. I have had many colleagues tell me that their interaction with patients is definitely affected both other people in the room. This is a factor that can affect both the conscious state of the psychiatrist and the person being interviewed.

Empathy: All psychiatric trainees learn a lot about empathy in early interviewing courses. The necessary prelude to empathy is therapeutic neutrality. That is a confusing term to nonpsychiatrists, but it essentially means not bringing in any extraneous interpersonal factors or emotions into the interview of a specific patient. That ability is gained by self-analysis, experience, and in some cases personal psychoanalysis. From the patient perspective, emotional reactions often surface as part of longstanding patterns of behavior. They are often proximate to the problem at hand and very relevant in the initial interview situation.

Empathy is taught as essentially a cognitive appreciation of the patient's emotional state. The single best definition of empathy is from Sims in his book on descriptive psychopathology. “In descriptive psychopathology the concept of empathy is a clinical instrument that needs to be used with skill to measure the other person’s internal subjective state using the observer’s own capacity for emotional and cognitive experience as a yardstick. Empathy is achieved by precise, insightful, persistent and knowledgeable questioning until the doctor is able to give an account of the patient’s subjective experience that the patient recognizes as his own.” Sims captures the dynamic basis of the interview in this definition. An empathic interview should result in a patient feeling very understood by the end.

Intellectual Capacity: The intellectual capacity of the patient may vary considerably based on the psychiatric disorder they are experiencing. By intellectual capacity, I am not referring to IQ scores. I am referring to the ability of both the patient and the psychiatrist to recall and process information and consider a maximum number of explanations for what the patient is going through.

Emotional Capacity: In the dyadic interview, the emotional capacity of both the psychiatrist and patient are important. Can the patient describe the extent of any emotional disruption and the time course of that process. Are they psychologically minded or can they appreciate social or psychological etiologies for these symptoms or do they view the problems as being treated only with a medication. Psychiatrists are to a large degree self-selected on the basis of their interest in emotional problems. Many psychiatrists have had first hand experience in families where members have had a mental illness or addiction. They had experience with all of the difficulties of getting that family member adequate treatment. They recognize that these problems are very real and are generally highly motivated to provide treatment and advocacy. As previously noted in the discussion of empathy, the ability to experience the emotional states of patients and describe them is necessary. Sampling one's emotional state during the interview can also provide insights about the interview process, diagnosis, and overall meaning of the information being discussed. As the average age of psychiatrists has increased, they have also seen thousands of patients with different kinds of emotional problems and successfully treated them.

Information Content: I find it surprising that the information content of diagnostic interviews is never estimated and the importance is never really taught. There may be a correlation with the length of the interview, but not necessarily. I can interview a person who gives brief high information content responses and do a reasonably good assessment in 30 to 45 minutes. I can talk with a person who digresses and gives a lot of irrelevant details and still not have what I need at the end of 90 minutes or an hour. The person who can assist me in doing the brief interview is not as common in my experience and I would say they represent 5% or 10% of the people I have seen. There are also the Augenblick diagnoses or ones that can be made in the blink of an eye. If I see a person with catatonia, delirium, or a stroke - I may not have to have them say anything to me. Those rapid diagnoses will precipitate a thought process about what else needs to be ruled out and what tests need to be done immediately to confirm the diagnosis. The information content in an interview is bidirectional and probably encompases severe channels including speech and paralinguistic communication. The paralinguistic channel also contains information about the affiliative behavior of the participants.

Therapeutic Alliance: An optimal diagnostic and treatment relationship flows from therapeutic alliance between psychiatrist and patient. In other words - both are working together on a problem or set of problems that is bothering the patient. It proceeds lie all patients interactions in medicine on an informed consent model. Acute care psychiatry often involves the assessment and treatment of patients who are being detained on an involuntary basis because of safety concerns and in that situation the psychiatrist can be perceived as an agent of the state. In that case and in many cases of long term treatment, it is often a good idea to review this principle with people in treatment to reorient them to the process. Even a person who is being briefly seen for medication can have a problem in treatment if they perceive a psychiatrist a being poised over a prescription pad, ready to address their briefly stated problems with a new prescription.

Structure: The psychiatrist has a responsibility to structure the interview so that the time is ultimately used to get results for the patient. That means a singular focus on the patient, how the patient is proceeding in the interview, and how they are presenting the information. That can mean giving additional information about the interview to the patient, providing necessary definitions, and doing whatever can be done to enhance the information content of the interview. The introduction to the patient is critical because to this day there is still confusion over the definition of psychiatry. I generally tell everyone my name, my years of experience, and present them with my business card. After that I clear up any questions about psychiatry. Some people ask about where I trained and I provide them with that information. Some ask for clarification about the interview as we proceed. A common question is: "Do you want the long version or the shirt version?" Some early questions are also red flags and may be an indication of strong biases by the person being interviewed that may even preclude the interview itself. Some of those decisions may also depend on the interview setting. An example might be religion as a selection factor. If a person tells me that they can only talk to a Christian using their specific definition and they want to ask me questions to determine my status, it might be easy to suggest that they see someone else in an outpatient setting, but a lot more difficult if you are the only available psychiatrist on an inpatient unit.

Technical Skill: Like most professions, there is some variation in the interview and interpersonal skills of psychiatrists. A psychiatric interview requires technical skills that psychiatrists have been focused on since early in their training. Those skills are the focus of courses, seminars, books, papers and direct observation by training supervisors. Since the oral board examinations have stopped, psychiatric residents now do the equivalent of oral board examinations on interview techniques during their training. During an interview, a psychiatrist is listening for patterns and inconsistencies. A psychiatric interview is not an interrogation. In an interrogation, the interviewer generally has a bias and asks very leading questions to confirm that bias. That style is evident in any number of police and crime television shows and films that are easily accessed these days. In a psychiatric interview, the psychiatrist is developing hypotheses about diagnoses and formulations and inconsistencies with those hypotheses. The interview itself can be very nonlinear and the psychiatric directs the interview from one major cluster of information to another. A parallel process during the interview is recognizing the person's mental state and its potential origins. Empathy as noted above is a critical aspect of that process.

Psychiatry is currently being practiced with an implicit rather than explicit focus on consciousness. Making consciousness more explicit adds a lot to assessment and treatment. The idea that every new patient being seen is truly a unique individual based on their conscious state is a primary organizing factor. Their experience of mental distress is unique and can only be categorized with the broadest categories. That emphasis creates a high bar for anyone who wants to be a good psychiatrist. That psychiatrist by definition will critique each interview while they are documenting it and consider what was missed. That psychiatrist will also critique any practice setting that requires them to interview patients according to electronic health record forms, diagnose people based on rating scales, or respond to patients in a stereotypical manner. The recent emphasis on collaborative care is also a dead end in terms of consciousness. The idea that a psychiatrist looking at rating scales and "managing populations" without ever talking to any of those patients is absurd from the standpoint of conscious states and diagnostic precision.

Human consciousness doesn't work that way and psychiatrists can't either.

12 comments:

This is a great post Dr. Dawson. Often times I wonder to myself if psychiatrists aren't going a good enough job articulating the expertise and skill set that they can offer. I think posts like these are great for raising awareness for what psychiatrists do. I wish there was available in some sort of official print that could be given to people!

I hope to get it published as a more academic paper, but thought I would get it out on this blog first to get feedback. Ideally, the communication section would also contain more theory. The thought that the parameters of an ideal interview have never been determined has always fascinated me.

What really strikes me about this post, and others like it, is that this type of information is not conveyed in a standard consult letter or history note, which is presumably where you document the important data points of the interview. Rather, we put down a laundry list of symptoms pertinent to DSM categories, which sounds less useful or possibly transient and up for interpretation. So wouldn't you advocate that the general bullet points or categories of our psychiatric interview, as it is taught and documented and communicated, be changed to include the things you write about here?

I would definitely advocate for an update in how this information is approached and recorded. I have said that the clinical approach to mental states and the way they are recorded has been with us for at least 70 years. Nothing has changed since I was in medical school over 30 years ago. Looking at the "mental status exam" section of any report provides very little discrimination between one person and the next with different psychiatric disorders or even organic brain disease.

Sure - psychiatric training. I want to emphasize that I think it is counterproductive to compare psychiatrists to other clinicians. I want to emphasize that relative to the training that psychiatrists get - the clinical method has been static for some time. The idea that a DSM code is all that is needed to make a "diagnosis" or in some cases a checklist based on DSM criteria is absurd and does not encompass a fraction of what psychiatrists are trained to do. Instead of pointing that out - we have people in the field celebrating the gross classification of large groups of people (managed care "populations") with very crude metrics like the PHQ-9 and proclaiming this is some kind of advance for the field. That is rather pathetic rhetoric from where I sit.

Practically all of the work that many psychiatrists do is ticking off bullet points on billing statements rather than thinking about the unique problems that their patients are presenting with.

Sure - psychiatric training. I want to emphasize that I think it is counterproductive to compare psychiatrists to other clinicians. I want to emphasize that relative to the training that psychiatrists get - the clinical method has been static for some time. The idea that a DSM code is all that is needed to make a "diagnosis" or in some cases a checklist based on DSM criteria is absurd and does not encompass a fraction of what psychiatrists are trained to do. Instead of pointing that out - we have people in the field celebrating the gross classification of large groups of people (managed care "populations") with very crude metrics like the PHQ-9 and proclaiming this is some kind of advance for the field. That is rather pathetic rhetoric from where I sit.

Practically all of the work that many psychiatrists do is ticking off bullet points on billing statements rather than thinking about the unique problems that their patients are presenting with.

Wouldn't it be nice if psychiatrists all refused the checklist approach you so rightly condemn and insisted on only writing narrative notes in the records. I do still send for patients' prior psych records, but most of the time they are completely and utterly worthless. And it doesn't matter where in the country they came from. The notes don't even include the criterior the doc used for making their diagnosis. They'll use words like "paranoid" without describing what they mean - e.g, does the patient have trust issues resulting from an abusive background, or are they delusional? If the latter, it would be nice if the note would actually say what the "delusion" was. If someone thinks that the CIA is blasting them with rayguns, for example, one can be at least reasonably sure they have some kind of psychosis.

I am certainly on record here pointing out that documentation, especially EHR template based documentation is voluminous and worthless. It is an embarrassment to anyone who has spent their professional life studying and refining their techniques.

The solution is also very simple - forgo all of the billing and coding bullet points for a diagnostic formulation and diagnosis that is coherent and makes sense. Of course governments and managed care companies will object because they think check boxes are documentation that some kind of billable work has been done.

Either that or they have just been blatantly wasting our time all of these years with the old maxim: "If it isn't documented it hasn't been done."

Today that translates to: "If the box hasn't been checked it hasn't been done." No confirmation that the patient had a conversation with intelligent life.

Thanks George. Importantly, "Mastering the Clinical Conversation" is NOT an ACT book, but rather "This book provides psychotherapists with evidence-based strategies for harnessing the power of language to free clients from life-constricting patterns and promote psychological flourishing. Grounded in relational frame theory (RFT), the volume shares innovative ways to enhance assessment and intervention using specific kinds of clinical conversations. Techniques are demonstrated for activating and shaping behavior change, building a flexible sense of self, fostering meaning and motivation, creating powerful experiential metaphors, and strengthening the therapeutic relationship."